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Most HIV positive women will be asymptomatic and have no major obstetrical problems during their pregnancies^{99,366,367,368,369}. They should receive similar obstetric antenatal care to that given to HIV-negative women, unless indicated by the need to provide specific HIV-related treatment. There is no evidence that there is a need to increase the number of antenatal visits, provided there are no complications of the HIV infection, although additional counselling time may be required. The care of the HIV positive woman during pregnancy should include ongoing counselling and support as an integral part of the management. Advice on the possible risks of unprotected intercourse during pregnancy should be provided.

Obstetrical management

Antenatal care of the HIV positive pregnant woman will depend on the woman's risk of experiencing an adverse perinatal outcome. To an extent this will be mediated by other obstetric risk factors and antenatal care will need to be tailored to the individual woman. Consideration can be given to the assessment of fetal growth, whether by regular uterine fundal height measurements or, where available, by serial ultrasound assessments.

Invasive diagnostic procedures, such as chorion villus sampling, amniocentesis or cordocentesis should be avoided where possible, due to a possible risk of infection of the fetus³⁰². External cephalic version of a breech fetus may be associated with potential maternal-fetal circulation leaks and the advantages and disadvantages of the procedure should be very carefully considered.

Examination and investigations

HIV positive women should have a full physical examination at the first visit. Particular attention should be paid to any signs of HIV-related infections [particularly tuberculosis], oral or vaginal thrush, or lymphadenopathy. Herpes zoster [shingles] in a young woman is often an early sign of HIV infection and current herpes lesions or the scars from previous infection may be found. Other co-existent sexually transmitted infections, especially syphilis, are common in HIV positive women^{96,97,370,371} and may increase the risk of transmission and the level of virus in vaginal and cervical secretions. Clinical diagnosis and treatment of vaginal or cervical inflammation, abnormal discharge or STI should be a priority. The pregnant woman should be monitored for any signs of HIV-related opportunistic infections and for any other intercurrent infections, such as urinary or respiratory infection. Maternal weight should be monitored and nutritional supplementation advised where necessary. The oro-pharynx should be examined at each visit, for the presence of thrush.

Laboratory investigations will depend upon the available resources of the health service. Syphilis testing should be undertaken, and repeat testing in late pregnancy may be advisable⁴⁰. A haemoglobin estimation is mandatory and a complete blood count should be performed and T cell subset investigations undertaken where possible. Anaemia is more common in HIV-infected women and repeated haemoglobin tests may be helpful. Viral load estimation may provide a valuable prognostic indicator, where available. A cervical smear should be performed if this has not been undertaken within the recent past. Colposcopy should be reserved for women who have an abnormal cervical smear result.

Medical treatment during pregnancy

The medical care of HIV positive women should be tailored to the individual needs of the woman. In general, pregnancy is not a contraindication for the most appropriate antiretroviral therapy for a woman or for most of the medical management of HIV-related conditions, but the risk to the fetus should always be considered, and treatment modified if necessary²⁹⁰.

The value of vitamin A supplementation in reducing transmission has not been proven, but multivitamins may provide cost effective nutritional support^372,373,374. Mebendazole should be given at the first visit in areas of high hookworm prevalence.

Malaria in pregnancy causes high maternal and infant morbidity and mortality, and may be associated with increased risk of mother-to-child transmission of HIV^216.217. Current recommendations are that intermittent treatment with an effective, preferably one-dose antimalarial drug should be made available to all primigravidae and secundigravidae in highly endemic areas. This should be started from the second trimester and given at intervals of not more than one month apart.

Prophylaxis for opportunistic infections should be given in pregnancy, as indicated by the clinical stage of the HIV infection, and according to local policy. Prophylaxis and treatment for tuberculosis should be given where indicated, although streptomycin and pyrazinamide are not recommended during pregnancy. Pneumocystis carinii pneumonia (PCP) prophylaxis should continue through pregnancy: sulfamethoxazole/trimethoprim (Bactrim/Septran) or pentamidine can be used. The risk to the fetus of maternal sulphonamide administration in the third trimester is outweighed by the risk to maternal health of PCP and kernicterus has not been reported where the drug was not also used in the neonatal period⁵. Consideration should be given to pneumococcal and Hepatitis B vaccination.

Treatment for opportunistic infections during pregnancy depends on the clinical stage of the patient. Treatment regimens should follow local policy guidelines. Where a variety of treatment options are available, those with the lowest risk to the fetus should be used. Dermatological conditions are common in HIV positive women and men, and treatment may be required for prolonged periods. Acyclovir can be used safely after the first trimester. Topical imidazole antifungals or topical gentian violet can be used throughout pregnancy and oral fluconazole can be used after the first trimester, if required.

Antiretroviral therapy

The use of antiretroviral drugs in pregnancy should be considered for two indications: the health of the mother and prevention of transmission^364,290,291. Pregnancy should not be a contra-indication for antiretroviral therapy in the mother, if indicated. The use of ZDV in the prevention of transmission to the fetus has been discussed above^375,376,377. Current recommendations for adult antiretroviral therapy are that monotherapy with ZDV is sub-optimal treatment and that two antiretrovirals with the possible addition of a protease inhibitor is preferable^{288,289,378,379}. Although there is a theoretical risk to the fetus from combination therapy, there is limited experience with the use of other antiretrovirals such as lamivudine, stavudine, and protease inhibitors in pregnancy. Some have recommended stopping these therapies during the first trimester and restarting the combinations, but this also carries a risk of developing resistance. Detailed recommendations have been released in the USA on combination therapy in pregnancy²⁹¹. As many of the newer compounds do not have long-term safety data following use in pregnancy, this should be discussed with the patients. The use of any antiretroviral drugs should be accompanied by an explanation of the available knowledge to the women and advice that there should be long-term follow-up of the child²⁷².